Provider Demographics
NPI:1124477484
Name:GUELZOW, MARK WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:GUELZOW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 ROWLEY DR
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-3244
Mailing Address - Country:US
Mailing Address - Phone:561-523-3216
Mailing Address - Fax:
Practice Address - Street 1:4101 MEDICAL CENTER DR STE 1C
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-6600
Practice Address - Country:US
Practice Address - Phone:315-637-7878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-08
Last Update Date:2021-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY301689207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine